2 Tenderness Grading Scale Grade I – mild tenderness to palpationGrade II – mild tenderness with grimace and flinch to moderate palpationGrade III – severe tenderness with withdrawalGrade IV – severe tenderness with withdrawal from noxious stimuli
5 Cervical Range of Motion Take a thorough history to be certain that these motions will not adversely affect the patient.Trauma causing fracture, dislocation, or vascular compromise would be contraindications to performing these tests.Note limited range of motion.Note pain location and character.
6 Normal Cervical ROM Flexion – 50 degrees or more Extension – 60 degrees or moreLateral flexion – 45 degrees or moreRotation – 80 degrees or more
7 Cervical Resistive Isometric Testing Evaluate muscle strength and state.Weakness may indicate neurological dysfunction.Pain indicates muscle dysfunction such as a strain.
8 Muscle Grading Scale5 – Complete range of motion against gravity with full resistance.4 – Complete range of motion against gravity with some resistance.3 – Complete range of motion against gravity.2 – Complete range of motion with gravity eliminated.1 – Evidence of slight contractility.0 – no evidence of contractility.
9 Vertebrobasilar Circulation Assessment Vascular Insufficiency may be aggravated by positional change in the cervical spine.Assessment of the vertebrobasilar circulation must be done if cervical adjustment or manipulation is to be performed.
10 Predispositions to Cerebrovascular Accidents Headaches, migraineDizzinessSudden severe head or neck painHypertensive
11 Predispositions to Cerebrovascular Accidents Cigarette smokingOral ContraceptivesObesityDiabetes
12 Cerebrobasilar Testing Positional change in the cervical spine compresses the vertebral artery at the atlantoaxial junction on the side opposite of rotation.In the normal patient, the diminished blood flow does not cause any neurological symptoms, such as dizziness, nausea, tinnitus, faintness, or nystagmus.
13 Clinical Signs and Symptoms of Cerebrovasular Episodes Vertigo, dizziness, giddiness, light-headednessDrop attacks, loss of consciousnessDiplopiaDysarthria
14 Clinical Signs and Symptoms of Cerebrovasular Episodes DysphagiaAtaxia of gaitNausea, vomitingNumbness on one side of the faceNystagmus
15 Barre-Lieou SignProcedure: Patient rotates head from one side to the other.Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, nystagmus.Structure affected: Vertebral artery on the same side of head rotation. Consider patency of the carotid arteries and the communicating cerebral artery circle.
17 Vertebrobasilar Artery Functional Maneuver Procedure: Palpate and auscultate the carotid arteries for pulsations and bruits. Instruct the patient to rotate and hyperextend the head.
18 Vertebrobasilar Artery Functional Maneuver Positive Test: If pulsation or bruits are present at either the carotid or subclavian arteries the test is positive.Structures Affected: It may indicate stenosis or compression of the carotid or subclavian arteries.
20 Maigne’s TestProcedure: Patient extends and rotates the head and holds that position for 15 – 40 seconds. Repeat on opposite side.Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus.Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.
22 Dekleyn’s TestProcedure: Patient supine, head off table. Instruct pt. to hyperextend and rotate head. Hold 15 to 30 seconds. Repeat opposite.Positive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus.Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.
24 Hautant’s TestProcedure: Pt. Seated, eyes closed, extend arms to front with palms up. Pt. extend and rotate head.Positive Test: Patient loses balance, drops arms, and will pronate the hands.Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.
26 Underburg’s TestProcedure: Pt. standing. Close eyes and assess equilibrium. Stretch arms and supinate hands. Then pt. marches in place. Then pt. extends and rotates head while marching. Then opposite side.
27 Underburg’s TestPositive Test: Patient loses balance, arms drift, hands pronate. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus.Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.
29 Hallpike’s ManeuverProcedure: Pt. supine with head extended off table. Support head and move it into extension. Then laterally flex and rotate. Hold 15 to 40 seconds. Repeat opposite. Then hang head in free hyperextension.
30 Hallpike’s ManeuverPositive Test: Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus.Structures Affected: Vertebral, basilar, or carotid artery stenosis or compression.
33 Clinical Signs and Symptoms of Cervical Strain or Sprain Cervical and upper back painCervical and upper back stiffnessCervical and upper trapezius tightnessReduced cervical range of motionCervical extensor spasm
34 Differentiating Between Strain and Sprain Cervical strain is an irritation and spasm of the muscles of the cervical spine with or without partial muscle fiber tearing.Cervical sprain is a wrenching of the joints of the cervical spine with partial tearing of its ligaments.
35 Categories of StrainMild: Slight disruption of muscle fibers with no appreciable hemorrhage and minimal amounts of swelling and edema.
36 Categories of StrainModerate: Laceration of muscle fibers with an appreciable amount of hemorrhage into the surrounding tissues and a moderate amount of swelling and edema.Severe: Complete disruption of the muscle tendon unit, possibly with tearing of the tendon from the bone or a rupture of the muscle through its belly.
37 Categories of Sprain Mild: Slight tears of a few ligamentous fibers. Moderate: More sever tearing of ligamentous fibers but not complete separation of the ligament.
38 Categories of SprainSevere: Complete tearing of a ligament from its attachments.Avulsion: A ligament that attaches to a bone is pulled loose with a fragment of that bone.
39 O’Donoghue’s Maneuver Procedure: Patient seated. Put the cervical spine through resisted range of motion, then through passive range of motion.Positive Test: Pain during resisted range of motion or isometric muscle contraction signifies muscle strain. Pain during passive range of motion may indicate a sprain of any of the cervical ligaments.
40 O’Donoghue’s Maneuver Structures Affected: Cervical spinal muscles and/or cervical spinal ligaments.Since resisted range of motion mainly stresses muscles and passive range of motion mainly stresses ligaments, you should be able to determine between strain and sprain or a combination thereof.
42 Spinal Percussion Test Procedure: Patient seated. Head slightly flexed, percuss the spinous process and associated musculature of each cervical vertebrae with a reflex hammer.
43 Spinal Percussion Test Positive Test: Local pain may be a fractured vertebra with no neurological compromise. Radicular pain may be a fractured vertebra with neurological compromise or a disc lesion with neurological compromise. A ligamentous sprain could also elicit pain upon percussion of the spinous processes.
45 Soto-Hall TestProcedure: Patient Supine. Press on the patient’s sternum with one hand. With the other hand, passively flex the patient’s head to the chest.Positive Test: Local pain could indicate ligament, muscular, ossous pathology or cervical cord disease. Suspect disc defect with radicular symptoms.
47 Rust’s SignProcedure: A patient with severe injury to the upper cervical spine will grasp the head with both hands to support the weight of the head on the cervical spine. The supine patient will support the head while attempting to rise.Positive Sign: The patient stabilizes the head. It might include slight traction.
48 Rust’s SignStructures Affected: This could represent severe muscular strain, ligamentous instability, posterior disc defect, upper cervical fracture, or dislocation.
55 Dejerine’s SignProcedure: Patient seated. Instruct them to cough, sneeze, and bear down as if defecating (Valsalva’s maneuver).Positive Test: Local pain or pain radiating to the shoulders or upper extremities indicates an increase in intrathecal pressure.Structures Affected: Space-occupying lesion.
56 Cervical Neurological Compression and Irritation Clinical Signs and SymptomsCervical pain.Upper extremity radicular pain.Loss of upper extremity sensation.Loss of upper extremity reflexes.Loss of upper extremity muscle strength.
57 Foraminal Compression Test Procedure: Patient seated. Exert strong downward pressure on the head. Repeat with b/l rotation.Positive Test: Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal capsulitis. Radicular pain may indicate pressure on a nerve root.
59 Jackson’s Compression Procedure: Laterally flex the head and exert strong downward pressure. Perform b/l.Positive Test: Local pain may indicate foraminal encroachment without nerve pressure or apophyseal joint pathology. Radicular pain may indicate pressure on a nerve root.
61 Spurling’s TestProcedure: Laterally flex the patient’s head and gradually apply strong downward pressure. If no pain is elicited, put the patient’s head in a neutral position and deliver a vertical blow to the uppermost portion of the patient’s head.
64 Maximum Foraminal Compression Test Procedure: Have the patient approximate the chin to the shoulder and extend the head. Perform b/l.
65 Maximum Foraminal Compression Test Positive Test: Pain on the side of rotation with a radicular component may indicate nerve compression. Local pain with no radiculopathy may indicate apophyseal joint pathology on the side of rotation. Pain opposite of rotation indicates muscular or ligamentous strain.
67 Shoulder Depression Test Procedure: Apply downward pressure on the shoulder while laterally flexing the patient’s head to the opposite side.
68 Shoulder Depression Test Positive Test: Local pain on the side being tested indicates shortening of the muscles, muscular adhesions, muscle spasm, or ligamentous injury. Radicular pain may indicate compression of the neurovascular bundle or thoracic outlet syndrome. Pain on the opposite side indicates a decreased foraminal space, facet pathology, or disc defect.
70 Distraction TestProcedure: Grasp beneath the mastoid processes and press up on the patient’s head. This removes the weight of the patient’s head on the neck.
71 Distraction TestPositive Test: If local pain increases, suspect muscle strain, spasm, ligamentous sprain, or facet capsulitis. Relief of radicular pain indicates either foraminal encroachment or a disc defect.
73 Shoulder Abduction Test (Bakody’s Sign) Procedure: The patient should abduct the arm and place the hand on top of the head.Positive Test: A decrease or relief of the patient’s symptoms indicates a cervical extradural compression problem (i.e. herniated disc, epidural vein compression, or nerve root compression).